Professionalism is characterized by the extent to which members of a profession are motivated by shared values that uniquely define the profession.1 Professionalism can be based on morals and ethics. Morals are the beliefs and values an individual personally holds about what is right and wrong. Morals are developed from a variety of culturally based experiences such as religious practices, education, social events, and professional activities.2 Ethics refers to a systematic examination of human conduct regarding what is right and wrong as individuals conduct themselves in their professional and personal endeavors.3
As athletic training and sports medicine gained recognition and respect in the medical profession, unique challenges emerged.4 There is much pressure on the athletic trainer and team physician in today's field of sports medicine. Coaches, administrators, parents, and the public judge the athletic trainer and often the team physician on how fast an athlete returns to participation.5 There are times when athletic trainers may fear that their livelihood is at stake by appropriately withholding an athlete from participation to protect the athlete's long-term well-being. Thus, athletic trainers may feel pressured to mitigate or even abrogate their professional and ethical responsibilities and best practices in health care to please their employer to protect their livelihood.5,6
As a health care profession, athletic training has established its own code of ethics. The National Athletic Trainers' Association (NATA) has established a Code of Ethics7 that its members are obligated to follow. Additionally, the Board of Certification (BOC) Standards of Professional Practice8 provide ethical standards for athletic trainers to remain nationally certified to practice.
There are four Principles in the NATA Code of Ethics.7 The themes of the NATA Code of Ethics Principles are:
Providing competent and compassionate care that places the primacy of the patient above any group, and advocating for the best medical care and safety of their patient at all times.
Compliance with federal and state regulations governing the practice of athletic training.
Maintaining and promoting high standards in their provision of services.
Protecting the patient's health and well-being by reducing any professional conflict of interest.
The NATA Code of Ethics is useful in assisting the individual athletic trainer to learn appropriate professional behaviors versus judging a particular behavior or situation.3 The NATA has a committee dedicated to professional ethics, the Committee on Professional Ethics (COPE). The COPE is dedicated to educating its members on the Code of Ethics and raising awareness to the value of ethical practice. The other responsibility of the COPE is to adjudicate alleged ethical violations of its members. As the current chair of the COPE, I have been fortunate to work with the dedicated members of the committee and help develop ethical education for the athletic training profession.
A key element of education is to raise awareness of particular situations where the athletic trainer may face ethical dilemmas. Below are a few of the potential ethical dilemmas that athletic trainers may encounter in meeting their professional obligations to the public and patient care.
Consider the following scenario: An athletic trainer working with a football team is managing a student-athlete who has sickle cell trait. The student-athlete has been ill recently, and is mildly dehydrated because of the illness. The student-athlete is a starting wide receiver and the final game of the season is tomorrow. The team needs to win the game to move onto the conference championship game. The student-athlete has confided to the athletic trainer that he is feeling subpar going into the game but does not want to be pulled from the game as a result of the illness and sickle cell trait condition. What does the athletic trainer do in this scenario?
Athletic training professionals have an ethical obligation to safeguard the long-term well-being of their patients.4 The ethical dilemma for athletic trainers working in a team sport setting is how to ensure the athlete's long-term well-being while navigating the competitive season.9 Making return-to-play decisions when emotions are running high for the athlete, coach, parents, and media can unduly and detrimentally influence return-to-play decisions. Some of the conundrums of making return-to-play decisions include:
Making decisions without taking the time to know state or national recommendations in care per organizing bodies (NATA, National Collegiate Athletic Association, and state mandates), or not following departmental policies and procedures due to pressure from others.
Taking unnecessary risks to inappropriately return an athlete for a big game because the athlete, coach, or parent requests the return for “the good of the team” or the athletic trainer is trying to “prove” his or her skills or worth by quickly returning an athlete from injury. In the scenario above, the student-athlete should be withheld from the game because of the increased risk of experiencing a sickling crisis as a result of exerting himself while ill and dehydrated.
The scenario above is one ethical dilemma that may turn inappropriate return-to-play decisions into ethical violations and perhaps legal consequences with a poor medical outcome. One of the primary elements of the NATA Code of Ethics is compassionate care. Consider Principle 1.2 of the NATA Code of Ethics on this topic:
1.2. “Member's duty to the patient is the first concern, and therefore members are obligated to place the well-being and long-term well-being of their patient above other groups and their own self-interest, to provide competent care in all decisions, and advocate for the best medical interest and safety of their patient at all times as delineated by professional statements and best practices.”
Clearly, the athletic trainer adhering to the above NATA Code of Ethics Principle would consider what is in the best interest of the patient/athlete's long-term well-being when returning that patient/athlete to participation at any time, especially during a competitive season.
Consider the primacy of the patient and informed consent. One consideration in the primacy of the patient is when the student-athlete and parents may not fully understand the consequences of continuing to participate with injuries. For example, there is evidence that not all student-athletes who are provided with concussion education fully understand the information or their obligation to report concussion symptoms to their athletic trainer or coach.10,11
Concussion management is a significant issue in sports medicine.12 Pressure to return the athlete to participation following a concussion in season challenges the athletic trainer's judgment in concussion management. Two critical areas of concern are not complying with state or national requirements or recommendations on concussion management, or not being up to date on current changes in concussion care. Consider the NATA Code of Ethics Principles 2.1 and 3.3 in concussion management:
2.1. “Members shall comply with applicable local, state, federal laws, and any state athletic training practice acts.”
3.3. “Members shall recognize the need for continuing education and participation in educational activities that enhance their skills and knowledge and shall complete such educational requirements necessary to continue to qualify as athletic trainers under applicable state athletic training practice acts.”
Athletic trainers are obligated to comply with any concussion management laws and keep up to date on current concussion management recommendations to provide quality health care to patients.
Another ethical obligation for the athletic trainer in protecting the long-term well-being of an athlete following concussion includes the areas of informed consent to continue playing following repeated concussions or to have the physician consider medical disqualification to protect the athlete from long-term consequences of repetitive concussions.13
Now that the United States Supreme Court has ruled that states can establish legalized gambling on sporting events, athletic trainers must be aware to not provide any health-related information on their patients and athletes to those not authorized to receive it, because gamblers would be interested in this information to place bets on inter-collegiate and professional games. An additional concern is that of athletic trainers placing bets on sporting events themselves or unwittingly providing confidential health information of athletes to those not permitted to receive it.14 All athletic trainers should abide by NATA Code of Ethics Principles 1.4, 4.3, and 4.4 to reduce any chance of being involved in unethical practices relative to the new gambling laws:
1.4. “Members shall preserve the confidentiality of privileged information and shall not release or otherwise publish in any form, including social media, such information to a third party not involved in the patient's care without a release unless required by law.”
4.3. “Members shall not place financial gain above the patient's welfare and shall not participate in any arrangement that exploits the patient.”
4.4. “Members shall not, through direct or indirect means, use information obtained in the course of the practice of athletic training to try and influence the score or outcome of an athletic event, or attempt to induce financial gain through gambling.”
One area for discussion is how does the profession of athletic training instill ethical practice among its members? One place to start is with athletic training education. At a time in athletic training education where athletic training students are learning the ever-expanding and complex technical and evidence-based practice skills of the profession, they are also failing to appreciate the importance of empathic care on the medical outcome of a patient.15,16
The professional education programs in health care, such as athletic training, are becoming more specialized to develop anticipated clinical skills. As a result, many athletic training professionals have little (if any) formal training or education in assessing and managing ethical dilemmas. Without appropriate strategies to resolve ethical dilemmas, athletic training professionals can be forced to respond to the pressures of the school or organization, such as from coaches, owners, general managers, athletes, and parents. Abrogating ethical practice may create a culture of “win at all costs,” promoting short-term decisions focused on winning rather than the long-term health implications for the student-athlete.3,17 Athletic training should integrate transformative learning into the clinical experiences, encouraging the learner in a consciousness-raising environment to promote critical thinking and reflections on important areas such as ethical practice.18
Athletic training professionals are dedicated to the primacy of their patient by their individual practice as an athletic trainer. The individual members of the athletic training profession, who take it upon themselves personally to attain and maintain a level of excellence in meeting their obligations and responsibilities, help ensure public confidence and respect. Ethical practice by each athletic trainer on a daily basis helps establish the professional excellence expected by the public and enhances the stature of the profession. It is not enough to know the NATA Code of Ethics; each athletic trainer must put ethics into practice alongside the care provided on a daily basis to attain personal and professional excellence.
- Madara JB, Burkhart J. Professionalism, self-regulation, and motivation: how did health care get this so wrong?JAMA. 2015;313(8):1793–1794. doi:10.1001/jama.2015.4045 [CrossRef]
- Scott R. Professional Ethics: A Guide for Rehabilitation Professionals. St. Louis, MO: Mosby; 1998.
- Schlabach GA, Peer KS. Professional Ethics in Athletic Training. St. Louis, MO: Mosby Elsevier; 2008.
- Mathias MB. The competing demands of sport and health: an essay on the history of ethics in sports medicine. Clin Sports Med. 2004;23(2):195–214. doi:10.1016/j.csm.2004.02.001 [CrossRef]
- Kroshus E, Baugh CM, Daneshvar DH, Stamm JM, Laursen RM. Pressure on sports medicine clinicians to prematurely return collegiate athletes to play after concussion. J Athl Train. 2015;50(9):944–951. doi:10.4085/1062-6050-50.6.03 [CrossRef]
- Wolverton B. Coach makes the call: athletic trainers who butt heads with coaches over concussion treatment take career hits. The Chronicle of Higher Education. September2, 2013. http://chronicle.com/article/Trainers-Butt-Heads-With/141333/
- National Athletic Trainers' Association. Code of Ethics. http://www.nata.org/membership/about-membership/member-resources/code-of-ethics. Updated 2016. Accessed November 11, 2018
- Board of Certification. Standards of Professional Practice. 2018 update. www.bocatc.org/system/document_versions/versions/144/original/boc-standards-of-professional-practice-2018-20180305.pdf?1520264560. Accessed November 11, 2018.
- Neal T, Schlabach G. Raising the standard of care through ethical return-to-play decisions. NATA News. 2018;30(1):14–15.
- Baugh CM, Kroshus E, Bourlas AP, Perry KI. Requiring athletes to acknowledge receipt of concussion-related information and responsibility to report symptoms. J Law Med Ethics. 2014;42(3):297–313. doi:10.1111/jlme.12147 [CrossRef]
- Walter KD. Addressing concussion in youth sports. Virtual Mentor. 2014;16(7):559–564. doi:10.1001/virtualmentor.2014.16.07.pfor1-1407 [CrossRef]
- Neal T. Ethical issues in concussion management. International Journal of Athletic Training and Therapy. 2017;22(1):24–32. doi:10.1123/ijatt.2016-0020 [CrossRef]
- Neal T, Konin J. Medical disqualifications: legal precedent and future considerations. NATA Sports Medicine Legal Digest. 2018;2(1):7–11.
- Mathner R, Martin C, Carroll M, Neal T. Extending sports wagering studies outside of the student-athlete population: NCAA division I athletic trainers' gambling behavior. Journal of Issues in Intercollegiate Athletes. 2014;7:431–444.
- Ward J, Cody J, Schaal M, Hojat M. The empathy enigma: an empirical study of the decline in empathy among undergraduate nursing students. J Prof Nurs. 2012;28:34–40. doi:10.1016/j.profnurs.2011.10.007 [CrossRef]
- Peer KS. Ethics education: preventing moral distress and empathy decline in sports medicine practice. International Journal of Athletic Training and Therapy. 2017;22(1):47–52. doi:10.1123/ijatt.2016-0024 [CrossRef]
- Peer KS, Schlabach GA. Uncovering the moral compass: teaching ethics across the curriculum. Teach Ethics J. 2010;11(1):53–71.
- Herbers MS, Nelson BM. Using the disorienting dilemma to promote transformative learning. J Excell Coll Teach. 2009;20(1):5–34.